Nokea
The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?
- A. Lithotomy
- B. Sim's
- C. Prone
- D. Trendelenburg
Correct Answer: D
Rationale: Trendelenburg position (head down, feet elevated) is used for lower abdominal surgery to improve access to the pelvic organs by shifting abdominal contents upward.
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The nurse is assessing a client with suspected glomerulonephritis. Which of the following findings would the nurse expect?
- A. Clear, pale urine.
- B. Hematuria and proteinuria.
- C. Polyuria and dilute urine.
- D. Absence of edema.
Correct Answer: B
Rationale: hematuria and proteinuria are hallmark signs of glomerulonephritis due to glomerular damage
A client has orders for placing a small-bore nasoenteric tube. Which finding in the health history would prompt the nurse to notify the prescriber before placing tube?
- A. small-bowel lesion
- B. basilar skull fracture
- C. acute coronary syndrome
- D. use of diabetic insulin pump
Correct Answer: B
Rationale: A basilar skull fracture is a contraindication for nasoenteric tube placement due to the risk of intracranial insertion. Other conditions are not absolute contraindications.
Which person is at greatest risk for developing Lyme's disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent exposure to tick-infested outdoor environments, where the disease is transmitted.
The charge nurse notices another nurse on the floor reading the chart of a client who is not under her care. When confronted, the nurse says, 'This client is my neighbor, and I'm just concerned about him.' Which is the correct response by the charge nurse?
- A. As long as you don't share any information, it's okay.'
- B. Why don't you just let his nurse update you on his status?'
- C. You should not be reading the client's chart if you are not involved in his care.'
- D. Go with the doctor when he rounds on this client so you will be able to answer the family's questions.'
Correct Answer: C
Rationale: Accessing a chart without a care-related purpose violates HIPAA and patient privacy, regardless of personal relationships.
The nurse is caring for a client who is having surgery the next morning. The client says, 'I'm really scared about surgery. I've never been put to sleep before and I'm afraid I might not wake up.' Which response by the nurse is the most therapeutic?
- A. Why are you worried about such a minor procedure?
- B. We can call the doctor and cancel the surgery if you would prefer.
- C. It's normal to be afraid of something new like surgery. Tell me how you feel.
- D. Don't worry, you have a really good doctor and he will see to it that nothing goes wrong.
Correct Answer: C
Rationale: Acknowledging fear as normal and inviting the client to express feelings is therapeutic, fostering trust and emotional support.